I'm Married to an ER Doc in NYC
superorganizers.substack.com
superorganizers.substack.com
It's basically condemning them to working nonstop for months if not years, watching people die all day long & being in infection danger at all times while at work.
And you can't replace all the people that burn out, get ill or die quickly - training medical professionals takes many years.
Almost all states very early on had some level of 'lock-down', stay at home order, or what have you. This has limited movement of people, and as a side effect, or maybe even direct order from governors, closed down/ limited many business. Including hospitals.
Hospitals in America, believe it nor not, are for profit businesses. It is un-intuitive, but many of them are in serious financial trouble, despite the influx of Covid-19 patients. At a cursory level, I think most people would assume the hospital business is booming, but this assumption couldn't be more wrong.
At this point, nobody wants to go in for routine examinations or non-emergency procedures. For-profit hospitals (almost all of them are) as a business, depend on providing these non-emergency services/ surgeries/ procedures. Hospitals across the country are laying off health-care workers en-masse.
So it is not correct to imagine all hospitals are running at full capacity, and burning out their workers. In fact, many health care professionals are drawing unemployment at this point.
I know this is doesn't make sense at the surface level, but it is something we all need to consider when continuing to advocate for lock-down or stay at home strategies. Our economy depends on movement of people/ goods/ services. That includes hospitals. I wish there was more serious discussion about this, and how we keep things moving as much as possible, while also protecting one another from spreading the virus.
Lock-down alone is not an solution. If your areas hospitals are at risk of reaching capacity, for sure close it down. But almost nowhere in America outside of NY/NJ is there a risk of that right now. We've tried it for a while, but now we have more understanding. Now I want us to re-imagine how we can continue a life of movement, and also reduce risk of infection.
We can be ideological and let hospitals fail and doctors and nurses get laid off, or we can be pragmatic and focus on what creates the best outcome as we navigate the reality we are in.
This is much harder in universal healthcare systems that are cost centers and thus can't just decide to change to a newer better method. Furthermore, the universal healthcare system have to budget who gets what kind of medicine. So while all people gets treated the same way not all illnesses does.
Everything have pros and cons. The US system is much better in some ways and have shortfalls in others and vice versa.
But - other people in this study didn't get the drug. I don't know if they were given placebo or just something else instead. My point being - they didn't survive, my dad did. After the study was concluded, the drug is now paid for by the national health service and anyone who needs Glivec can get it.
So why isn't this a critique of the nationalized system? Well, because the way I see it - in a private health care system, no one in this group would survive, because no one in Poland could ever afford this treatment. At least some of the people were still given a chance because the system has enough flexibility to at least try new and experimental treatments.
The US has the best healthcare system in the world--if you're a millionaire.
I have a hard time rationalizing his recent experience with the assertion that you have to be a millionaire to receive top-flight care.
Meanwhile I am glad I live in a society with a nationalized health system where births cost nothing.
I just go with a PPO because that seems less crappy than the alternative. If anyone knows what metric leads to outcomes like my friend's (I'm not being facetious here), I would like to know.
Nitpick: Over half of US hospitals are nonprofits or government owned [1] though I believe hospitals are vastly outnumbered by private clinics and independent practices. Doesn't change your overall point - even the hospitals run by governments, the Catholic church, and other institutions have budgets and are watching their main incomes disappear without much hope for the near future.
Government owned is only meaningful with the Federal government, which has unlimited resources.
My wife is a nurse for Dignity Health (another "nonprofit" hospital here in California) and has been effectively laid off for the last couple months. It's great that the ER is empty, but in the mean time nurses are struggling and people aren't getting their cancer screenings. If this goes on long enough, our healthcare system will fall apart from atrophy, not from overuse.
Why is that? You don't think they lay people off in Canada or Japan when there's no patients? Even single-payer systems can have private hospitals. They are simply paid by the govt instead of (or really in addition to) by patients. They still need business and to balance the books.
Canada has a similar mix of all kinds of hospitals like the US, though it may be more slanted in some way.
Source: https://en.wikipedia.org/wiki/Kaiser_Permanente#Operations
Huh? It is exactly what I think of when I use the term non-profit in the context of a healthcare maintenance organization. I truly have no idea what you mean by your quoted statement.
Not only are no non-essential activities happening, many essential ones are also being pushed back and people are dying as a result. There are multiple stories of people not being able to go for dialysis because hospitals insist on a negative COViD test to admit you and authorities don't allow you to get tested if you are not showing COViD symptoms. It is a catch-22 that can be resolved only if you are well-connected or rich.
Also, in knock-on effects, immunization programs are severely impacted, and many infectious diseases are likely to make a huge comeback with the monsoon season since typical mitigating measures for those were put on hold. The non-COViD death toll will be massively above typical years.
People on the prudent/cautious camp are missing that lockdowns are really last-resort, expensive controls at the bottom of the pyramid, used when better controls fail.
We can't just netflix and chill for the next two years. But we can't just pretend nothing is wrong either!
This was apparently effective with cases limited to a few clusters at the moment & most of the lockdown restrictions removed by now.
Were the hospitals affected ? They did report funding shortfals right after the lockdown due to all the cancelled elective procedures, so the ministry of health simply gave them extra money to cover the lockdown loses. And at the moment most hospitals are back to normal workflow.
Also, the people involved in directly handling the infection got bonuses as a thank you for doing the needed but dangerous work.
(I would guess that Kaiser might be doing somewhat better since they're paid monthly but their finances aren't easy to find.)
Medicare pays on a set scale for performance. If you have a heart attack, they pay a fee for the surgery and x days of hospitalization and x days of rehab. If the hospital gets you home in x-3 days, they make money. If the hospital fucks up and you get an infection and stay for x+10 days, they eat it.
Medicaid is a PPO that pays on a per procedure basis. Their rates suck, but they don't care about quality for the most part. There's a billing optimization process to maximize revenue for poor old people. (Some things are better billed to Medicare, others to Medicaid)
Private insurance pays for whatever they cover at a rate of y+z% over the Medicare rate. The patient gets the bill for whatever else happens.
Uninsured get whatever treatment is legally necessary. They patch you up, take a loss, kick you out and do it again when you come back.
Not only are hospitals for profit, but their part of cartel-like health networks. For some jobs, its hard to jump because 80% of the work is affiliated with two companies regionally.
No it makes perfect sense, and it doesn't matter if it's 'nonprofit or for-profit' - the inefficient use of resources is just the same.
Hospitals are the most expensive places in the world to run, with very highly trained personnel, gear, etc.. In a socialized system, if they are not used, it's a massive inefficiency.
Now imagine a system where 10's of millions of people are in economic pain - but they still have to foot the bill for unused medical services via taxes.
It's just shifting around deck chairs with respect to where the pain will be borne.
Obviously this is a bad state of affairs. But it's important to understand the reality we're in rather than indulging in fantasies.
This seems an important point to remember in most US public discussions. If people can't even agree on basic facts, how can you make decisions?
So my question is more like, how are countries that, in say six months, that’s population only have 10% exposed to COVID-19 going to coexist in a global world with countries that are past herd immunity and operating freely again.
Covid is a new disease. Will it have long term effects?
I've been following the research since December/January on New England Journal of Medicine, Virological.org, Lancet etc. And I think there is not yet enough evidence to suggest that there is immunity conferred by contracting Covid-19.
Does anyone know of any studies claiming that "herd" immunity is even possible with Covid-19? The latest article I could find is: COVID-19 and Postinfection Immunity https://jamanetwork.com/journals/jama/fullarticle/2766097
If there is no immunity or limited immunity conferred from infection then Covid-19 will be with the USA and other countries that have given up on control measures for a long time.
I suppose this depends on what the null hypothesis is? Is the null hypothesis "You have immunity after being infected" or is it "You don't have immunity after being infected". You assume it's the latter and you're saying there's not enough evidence to reject it. But you could just as well assume it is "You have immunity after being infected" and we're gathering evidence to see whether that can be rejected or not.
https://podcasts.google.com/?feed=aHR0cHM6Ly9yc3MuYXJ0MTkuY2...
https://www.mvcr.cz/mvcren/article/coronavirus-information-o...
There is a map with green, orange and green countries.
UK and Sweden are red, most of western Europe orange.
For green countries, Czech citizens can go there and back without the need to present negative tests results and enter quarantine. Same thing for residents and nationals of those countries.
For orange countries, Czech citizens can go there and back without the need to present negative tests results and enter quarantine. Residents and nationals of those countries are banned from entering Czech Republic.
For red countries, Czech citizens can go there but need to present negative tests results and enter quarantine. Residents and nationals of those countries are banned from entering Czech Republic.
Possibly for most, but for New Zealand and Australia it looks ok.
It's great that we've got rid of the virus for now in NZ, but yes, there are many questions, including whether there will still be an incentive to even try for a vaccine once major countries reach herd immunity (if and when that happens).
But it truly astonishes and depresses me that the US - the country that went to the moon, that invented the internet, that built a military capability that literally saved the world in ww2 - seems to have given up.
How hard would it really be to do proper contact tracing in a population of 300 million? Yes it's a big job, a very hard job, but the big jobs, the tough jobs, that's what Americans do!
two of those are in part result of propaganda
Eh, no.
We (the USA) did really go to the moon, though I know some USA citizens dispute that.
It was really USA universities and corporations (with DARPA funding) that built the foundations of Ethernet, TCP/IP and the Internet. Yes, plenty of contributions from others (including foreign grad students), but still, USA institutions.
The USA produced a lot of war material for all the Allies in WW2. A lot went to the USSR to keep them in the fight. This in no way should diminish the absolutely unprecedented loss and sacrifice of the USSR peoples in the Great Patriotic War, who bore the brunt of it. But without the USA, I really doubt the Allies could have stopped the Axis powers.
It was a team effort - without combined efforts of the USA and the Soviets (and to a lesser extent the UK) the Axis powers might have prevailed.
Sometime near the end of the cold war I realized that the West's propaganda machine was in fact better than the Soviet version. Nobody in the USSR believed "Pravda" but everybody believed the NBC Nightly News. :)
One might argue however that we need such a mechanism since in 2020, as the Scots might say:
"People can ni' agree on the color o' Shite"
Regarding defeating the axis and specifically Germany (Italy was not a military colossus) there is data that shows that the USSR had a bigger impact in defeating the nazis.
No one denies the contributions of the US in both of those feats, but also it is undeniable that the narrative isn't always factually true.
how come? wouldn't without lockdown the herd immunity with that R0 would come in like 2-3 months (and during that period the vulnerable people would have to be locked down), while with lockdown we're already 3 months into it without reasonable lockdown based endgame in sight?
Simplistically, we don't want to lockdown or distance until we get to whatever that herd immunity level is. And then, a bit past that level, we might want to lockdown hard and then ease up to a steady-state lockdown, and then hold it there until the disease has passed.
The reason we'd lockdown hard and ease up is because, well, a continuity argument -- more lives are saved if you do a week of hard lockdown when 1000000 people are infected than if you wait until 10 cases remain.
So I have no doubt that working as health worker without enough protective gear is scary when you see healthy collegues getting sick.
But that does not mean that going for herd immunity is a bad thing. We know now that most people even don't know they have the virus when they were just exposed a little bit to it.
And if the virus travels like an aerosol it might even be true that the world wide protests that are going on in the open air won't lead to much more sick people.
But this also means that people inside a bad ventilated building are at risk.
Edit: an example of an article that explains this more in depth: https://www.webmd.com/lung/news/20200527/aerosol-scientist-c...
One way or the other, end game is herd immunity. But when you let it just "go freely" you overshot - more people then is necessary for herd immunity will get sick.
Studies [1] have shown that "20 percent of Covid-19 cases accounted for 80 percent of transmissions"
And those 20 percent were mostly 'Superspreading events'. We now know almost all those events were inside in bad ventilated areas.
[1] https://www.nytimes.com/2020/06/02/opinion/coronavirus-super...
Not to mention, the vaccine needs to work on the correct strain AND be administered to what, 70% of the population?
I don't get that tho. Supposedly accordingly to all stats, its as bad as its been before. We have 800 to 1,000 death per day and are on record to hit 200k death by September. How come I heard that the pandemic has slowed down yet... according to numbers its been the same.
You can see that NYC is way down from the mid-April peak, but the USA as a whole is tailing off much more slowly as new outbreaks elsewhere offset the declines in areas that were initially hit hard.
(But still, note that "way down" for NYC is still around 500 new cases per day.)
https://www.washingtonpost.com/graphics/2020/national/corona...
That being said we know practically nothing actionable about the spread of the disease, little more than we did when it started. Clearly the combination of masks and social distancing has slowed the spread but we don’t know how much good if any the masks really do, and we can’t never go outside again. It’s a waiting game, and a game of seeing just how much isolation we can collectively stomach. Unpleasant, and the end is certainly not yet in sight.
Somebody needs to tell that to Brooklyn residents. Streets are crowded.
Brooklyn residents crowding the streets are agreeing with that sentiment.
Fingers crossed I guess, but given that 1) the virus is still around AND 2) we do not have a vaccine AND 3) we do not have herd immunity, I can't say I feel very optimistic about the next month or so.
But a medical professional's subjective experience is local, and the US is a big place. Some regions are still (sigh) growing, and are indeed "as bad as it's been". But New York is now recording new cases at less than 10% of its peak from April.
Broadly: much of the country, and all of the worst hit areas, have this beaten now, as long as we don't lose control when relaxing lockdown rules. That's good news.
And the areas that don't have it handled well are, at the very least, not growing in an out of control exponential mode. That's good news too.
Stay home. This is the home stretch.
New infections per capita in the US are not falling and are an order of magnitude higher than in Western Europe. Israel brought new infections down to a few cases/million until they opened schools back up, now they are in line with Western Europe.
The trouble is that there are superspreading events, someone brings the virus to church or university, and everyone present gets it. There are reports of outbreaks in farmworker accomodation and consequent failures of the vegetable harvest. This isn't over at all and only getting worse when cash-strapped universities insist that their students come back on campus in August.
Many southern states are rising rapidly, as well as in the southwest.
Here in NC we're double what we were a month ago in both daily new cases AND current hospitalizations.
[1] https://www.theguardian.com/world/2020/jun/09/coronavirus-ca...
We cover non-pandemic stuff too.
We can’t however cure the virus. And if it progresses far enough then no amount of oxygen will save a patient. These cases are hard because we have to watch someone die without any means to save them. Doing cpr on a patient with covid can feel pointless. If the lungs do work then no amount of chest compressions, oxygen, and cardiac drugs will save that person.
I first encountered the concept in a new york times article where the interviewed nurse was saying the problem was people got bored and stopped doing it. That sounded... dumb. And as though being prone should be plastered all over the public health recommendations.
Proned patients are just people lying on their stomachs, are they not? I get that its something you would recommend to someone who is really low on oxygen, but why aren't people who aren't too sick to survive at home being told to do this also? Is there a downside?
Like if your pulse oximeter starts readying 88 and slowly dropping, its probably a good idea to start proning, in the very least at night while sleeping?
https://www.evms.edu/covid-19/covid_care_for_clinicians/#d.e...
A few months later, a friend who works at the hospital told me: I wish you had called me, I could have gotten you a room. And I thought: this is just like a third world country, where you need connections to get basic care.
I have never found this to be the case.
Generally, if I was fighting with a doctor, it was because he was trying to be too aggressive and do too much, not too little.
But if they feel you know medicine or are capable of understanding medicine or have a drive to learn more about your condition, then they will try harder, do more tests, ask more questions, etc.
Well, I was admitted and personally walked out with a gall bladder about to explode. Yeah, I was back in the hospital 24 hours later ... not my finest hour. So, I can absolutely confirm that you can be stubborn and buck the system.
I will absolutely defend your ability to spend time and research your treatment when dealing with doctors normally--especially for chronic conditions. Doctors page fault on every patient and if you are being responsible you may very well be better informed than your general practitioner about what is going on with your body.
However, if you are actually admitted to a hospital with something acute, do you really have the wherewithal to diagnose and manage it? By the time I hit the hospital, I was probably on 72 hours with very little sleep and pain that took hydromorphone to even dent. I guarantee I wasn't thinking clearly by then.
The biggest problem with hospitals is that you need an advocate for you, personally. Without someone in the room with you, you won't know if the nurse missed that medication round, isn't paying attention to your increasing temperature, didn't bring you your lunch, etc.
The problem isn't when the system works. The problem is that without someone else there you don't have someone to watch for if the system hiccups.
Just checked and it is quite the stark difference.
https://www.npr.org/sections/health-shots/2020/05/15/8567680...
Quote from the article
Old information:
Early reports from China, the United Kingdom and Seattle found mortality rates as high as 90% among patients on ventilators.
And more recently, a study of some New York hospitals seemed to show a mortality rate of 88%.
The mortality rate among 165 COVID-19 patients placed on a ventilator at Emory was just under *30%* .
And unlike the New York study, only a few patients were still on a ventilator when the data were collected.Old information:
Early reports from China, the United Kingdom and Seattle found mortality rates as high as 90% among patients on ventilators.
And more recently, a study of some New York hospitals seemed to show a mortality rate of 88%.
New information:
The mortality rate among 165 COVID-19 patients placed on a ventilator at Emory was just under 30% .
And unlike the New York study, only a few patients were still on a ventilator when the data were collected.
Anecdotal evidence seems to be that the doctors are getting better at treating the worst Covid patients. It's still not something you want to get, but it's not quite the death sentence it was.
Apparently, high-flow ventilation is a big improvement over intubation, but until everybody had enough/proper protective equipment it simply wasn't on the table (it aerosolizes the virus).
Which drug cocktails help and how to administer them is also improving.
We're not getting a good treatment until monoclonal antibodies or a vaccine, but were not simply standing still, either.
It could but they look fairly young and as long as they’ve no comorbidities they’ll be fine.
So why aren’t we focusing all the attention and effort on protecting the most vulnerable, instead of spreading misinformation like “COVID doesn’t discriminate” (it does) and panicking over schools while sending confirmed positive patients back to nursing homes?
The other bit of widespread misinformation is the 2m/6ft distancing thing. It's just an arbitrary number.
Weirdly the fearmongering makes me feel like being less careful, not more. The way I see it, if COVID is really so contagious that I'm likely to catch it from a stranger's exhaled breath as I pass them in the street, then I'm guaranteed to catch it eventually, so what's the point?
I'm sure it can technically be transmitted in this way, but what's the actual probability? Tiny enough to not be worth worrying about, I expect.
Higher initial dose results in worse outcomes. Low dose still helps build immunity. Covid19 should be assumed to work like other RTIs.
(This is also why obsessively washing your hands and cleaning your house with bleach isn't a good idea, because being in too sterile an environment harms your immune system.)
Hm, okay, at first I just saw the very linear response and wasn't sure how that translates low dose still helps build immunity, but then went back and read your comment up thread, which captures it better: the partial sickness gives partial immunity, thus "priming" the body for the full-blown thing.
Though getting the active transmission rate down could be more important in some places.
Why do doctors and nurses walk around outside in their hospital scrubs? It was unsanitary even before COVID and I just don't get it. How hard can it be to change into street clothes before leaving the hospital?
I see nurses and doctors in scrubs on public transit, in coffee shops, cafeterias... they are either taking whatever illnesses were in the hospital outside, or taking the dirt and grime of the outside world into the hospital. It's baffling that this behavior is so normalized that it's described as heroic in TFA.
Realistically, I would think scrubs are common because 1) they've become emblematic of healthcare occupations[1] and 2) they're easier to clean and relatively cheap--they protect the wearer from spills and contamination, not the other way around, and in contrast to traditional nursing uniforms, doctors' white lab coats, etc, they're comparatively disposal, so you can wash them in hot water after every use and then discard them after the fabric wears out.
[1] Undoubtedly because of their association with surgery. I'd bet it all started with some cool surgeon lazily wearing his scrubs around the hospital.
Realistically, cross-contamination in the hospital is almost certainly far more dangerous and consequential. Hospitals are full of infectious people, afterall, and why MRSA is more common in hospitals than in other environments. I'd rather be treated by a garbage man fresh off his route who's more mindful about what he touches after washing his hands and after touching something possibly contaminated, even if his clothes are filthy.
No, they put clean ones on, then put something sterile over the top. The racks of scrubs are used by everyone. You just grab a pair. You check the crotch doesn't have a hole in it, and that the elastic is still stretchy.
Remember too, sometimes folks are on the way to work in their scrubs, not necessarily leaving work.
If a neighborhood yoga studio can provide a place to change, pretty sure any healthcare facility can too.
I don't think it's a bad idea to make big investments into such infrastructure now but I think it's completely reasonable it wasn't a priority before.
[1] The average hospital with 50 to 99 beds has a FT+PT staff of about 400 ( beckershospitalreview.com/hospital-management-administration/50-things-to-know-about-hospital-staffing.html ) and half of all hospitals in the US have under 100 beds.
This is a weird thing to remind the parent of, considering the original comment says
>> they are either taking whatever illnesses were in the hospital outside, or taking the dirt and grime of the outside world into the hospital
I doubt there is a lid on the toilet.
Bad analogy, but its like using a car to get to work instead of riding your bike. Most do it, knowing its worse for the environment.
Where do the scrubs get washed, then? Do they need to bring a special bag to transport the scrubs so they can wash them at home? Does the bag need to be washed, too? If they leave the scrubs in the lockers if they "aren't too bad" (ha), how are the lockers cleaned to ensure that they are sanitary when they put their street clothes in? How do you ensure they are sanitary when their street clothes are removed? How does all of this adapt to them changing to street clothes to eat lunch, like you suggest? Are you willing to pay for more doctors/nurses/etc. to cover the changing time for lunch?
And if for some reason the clinic doesn't wash linens, well, presumably the scrubs are being washed at home now, so that's always an option. The "special bag" you refer to can be gym bag or a disposable plastic bag. That is still miles less gross than the status quo.
If a gym-goer can be expected to not work out in street clothes/shoes, surely similar standards of hygiene can be expected of healthcare practitioners!
Scrubs you see (assuming you don’t work in a procedural space) are not procedural scrubs. They are just clothing. You can be forgiven for being confused as many of those suits are taken / borrowed / stolen from the procedural scrub supply. This problem is serious enough in some places that scrubs are distributed with a vending machine system that tracks your (limited) allowed balance of outstanding sets.
A long time ago , when nurses and house officers worn uniforms and laundry was on site , non procedural clinical staff were wearing hospital laundered clothing. The uniforms, and the laundry service that went with it, went away decades ago though.
What to wear instead, in non procedural spaces, wasn’t every really clarified. I suspect Grays Anatomy and Scrubs helped to sort it out for this generation (although it’s highly regional and reasonably local) as did the economic importance of procedures.